Preoperative evaluation and Management of
patient withHematologic
Problems
Preoperative evaluation
1. Disease : severity : curable
2. Surgery : emergency : risk of bleeding
Hematologic problem
• Anemia• Bleeding tendency
– Platelet : thrombocytopenia , dysfunction
–Coagulopathy– anticoagulant
• Hematologic malignancy
Low risk
• Nonvital organs • exposed site• limited degree dissection• Local hemostatic effective
Moderate risk
• Vital organs • deep or extensive dissection• Local hemostatic ineffective
high risk
• local fibrinolysis • CABG, brain injury, extensive malignancy)• Bleeding complications compromise result
Bleeding risk procedure
Anemia
Perioperative transfusion
European Journal Of Haematology July 2005Preoperative transfusion in sickle cell disease : a survey of practice in England
Complication transfusion1. independent predictor of postoperative
infections 2.new transfusion hazards : West Nile virus
and variant Creutzfeld Jacob disease 3. iron overload 4. red cell alloimmunisation• Review : transfusion not improve
postoperative complication• No RCT : transfusion VS non transfusion
Vamvakas EC . Meta-analysis of randomized controlled trials investigating the risk of postoperative infection in association with white blood cell containing allogeneic blood transfusion : the effects of the type of transfused red blood cell product and surgical setting . Transfusion 2004;16 : 304 314 .
• preoperative Erythropoietin• - < 7 8 g/dL should be given• Except : severe ill , >55 year ,
cardiac diseasae
Perioperative transfusion
Anemia
Iron deficiency anemia
• Elective surgery : postpone: Hct > 10 g/dL
• Emergency : Hct 8-10
Thalassemia
HCC syndromeHypertensive, Convulsion, Cerebral
hemorrhage• Risk : thalassemia major, Hct 9-20%• Onset : during 2 week ( cmm< 2 days)• Mortality 33%• Etiology : volume overload pressor
hyperresponsiveness, RAAS system, symphatetic
• Prevent : slow rate ,< 3 pack/d , interval 3 days, monitor BP,
• diuretic ,antihistamine before transfusion • Rx : diuretic , antihypertensie,
dexamethaxone
AIHA Laparoscopic Splenectomy
AIHA
2 . Transfusion : most patients tolerate serologically
incompatible blood
2 . corticosteroids 1. suppress HPA axis:
prednisolone ≥ 5 mg/day for - > 3 weeks 6 12 months prior to surge
ry LLLLLLLL LLLLLLLLL LLLLLLLLL.
2. Impaired wound healing 3. Increased risk infections,
4. gastrointestinal hemorrhage
uiz ผู้��ป่วยหญิ�งไทยคู่�� 35 ป่� เป่�น SLE (DLE, ANA,anti DsDNA,LN) on prednisolone (5) 2*2Dx MCA with abdominal injury need Explor laparoscopic CBC : Hct 21 , WBC 1,600 N 75 % L 20% Plt 600,000 )Peripheral blood smear
uiz• blood transfusion Hct 25• Steroid stress dose
uizผู้��หญิ�ง 18 ป่� CVT consult preoperative mediastinal mass พบ anemiaCBC : Hct 18 WBC 5,600Plt 560,000
Thrombocytopenia
• surgical bleeding low risk < 50,000/dL moderate to high risk < 100,000
/dL• standard dose - 0102: . .
u/Kg• - 58 units for prophylactic• - 610Single donor platelets =
LLLLL • Maintain postoperative 1 week
Thrombocytopenia
2. Antifibrinolytic
1. Tranexamic acid 2. epsilon aminocaproic acid (EACA)
• areas increased fibrinolysis,• - 7 14required for days depend on L
mount of tissue injury.
plasminogen
Plasminogen activator Tranexamic acid
3. microfibrillar collagen, fibrin glue
• Two plasma proteins; fibrinogen and thrombin
• are being used to develop fibrin glue
Refractoriness to platelet transfusion
American Society of Clinical Oncology
corrected platelet count increment (CCI), CCI = increment platelet count 1 h r) x BSA [m(2 )]
unit of platelets
• practical : 10000, /d L• 6 units to BSA 2 m2• 10,000= increment x2 platelet ~ 30,000/dL
at 1 hr 6
• refractoriness = CCI < 5,000~ absolute platelet count increment
≤2000, /dL /unit
Refractoriness to platelet transfusion
Vancomycin , amphotaracin B
alloimmunization1. - HLA matched platelets2. S ingle donor c - rossmatch compatible
platelet with patient's serum3. +/- IVIG , plasmaphoresis
avoid transfusion 1in . TTP/HUS
- 2. heparin induced thrombocytopenia.
worsening neurologic symptoms and ac ute renal failure,
ITP• Splenectomy• 50000platelet count > , /ตL 1. Pulse methylprednisolone : resp 4.7
day2 .LLLL 1 gm/kg IV, repeated following day if
5 0 000 LL 60% resp in day 3
3. Anti Rh D 4. platelet5. Emergency splenectomy : response
in 24-48 hrs
Infection • 2immunize weeks prior : at time of diagnosis.
Alternatives 1. splenic irradiation 2. partial splenic embolization.
postsplenectomy
Platelet dysfunction
Agonist
Adhesion
1. Bernard-Soulier synd2.vWF 2.1 congenital
PltFc VIII 2-3 daydDAVP
2.2 acquired 1. Ab : AI, Lymphoproliferative 2.absorb vWF : Lymphoma,WM
Rx cause
Secretion
1.Acquire storage pool disease :
1.1 CABG, activate clot i.e. DIC
1.2 CLL, myeloproliferative 1.3 ; Cirrhosis , SLE2.Drug : NSAID ,
dipyridamole
Mild Rx causePlt dDAVP
Aggregate
1. Glanzmann , antiPlt Ab: SLE, ITP
2. Dysproteinemia3. Drug , plavix,fibinolytic
PLt Ab NovosevenRx underlying
Mixed Uremia
Antiplatelet
2 0 0 4 ACC/AHA task force: not discontinue in CABG after STEMI
Platelet transfusion prophylaxis???
1. ASA: irrevesible : 5-10 days
2. . : 2 days3. ticlopidine and
clopidogrel : irreversibly : 7-10 days4. LLLLLL : 3 days
Antiplatelet
COX -2 ???
both aggregation , adhesion . 1. Intrinsic factors : GP,
ADP, TXA2 2 Extrinsic factors
1. uremic toxins ( guanidinosuccinic acid and phenolic
) NO production (inh
aggregation), 2. anemia, 3. impair vWF-Plt interaction
Uremia
aggregation ,adhesion
Correlate ????
uremia1. anemia Hct - 25 30
2 . Erythropoietin –increasingGPIIb/I I Ia
and improving platelet calcium signLLLLL
3 50. effective % patients 1improvement within hour and
- 4 24lasts hrs.• Repeat every 24 hrs• tachyphylaxis due to depletion of endothelial multimer stores. , limit 3
dose
4.Dialysis 5.Estrogen : due to decreased generation NO.
6. Cryoprecipitate – - 10 12 24units every hrs : eff
ect = LDAVP
uizชายไทย 34 ป่� CKD จาก polycystic kidney diseaseOn regular hemodialysis 3 /สั ป่ดาห" น ดมาท$า kidney transplantation• regular hemodialysis• Hct >30
uizDM , HT , CKD Cr 2.5 มาด�วย acute febrile illness Dx melioid sepsis , acute ontop chronic kidney disease , severe metabolic acidosis , plan acute peritoneal dialysis• bleeding time < 7 min• cryoprecipitate or dDAVP
Coagulopathy
FRESH FROZEN PLASMA• all coagulation factors• 1 units : 250 mL;• 1 cc = 1 % activity• hemostasis when factors activity ~ - 25 30
% of plasma volume(40 mL/kg,)
= FFP at 10-15 mL/kg, Indications
• multiple coagulation factors• DIC , warfarin overdose, vitamin K deficien
cy, liver failure, massive transfusion• Every 6 hrs ( T1/2 factor VII 4-6 hrs)
30% x 40 cc/kg= 12 cc/kg ~10-15cc/kg
15 cc/Kg x 50 Kg = 750/250 = 3 bag
CRYOPRECIPITATE
• factor VIII, XIII, fibrinogen, fibronectin, vWF
• - volume of 10 15 mL.• fibrinogen = 200 mg• Factor VIII = 1 0 0 u - (80 110 IU)
1 .deficiencies of fibrinogen : 1 bag / 7Kg BW
2.vWF : 0.1 bag /kg every 6-12 hour3. Hemophilia A
1. Decrease production coagulation factor( vWF )
2. dysfibrinogenemia3. Decrease protein C , protein S, impair
ability to clear activated coagulation factor DIC
4. Vitamin K deficiency5. Thombocytopenia, Plt dysfunction
Rx1. FFP PT < 3 S , Plt 2. Vit K : PT normal in 12-24 hrs3. Cryoprecipitate : hypofibrinogen
Liver disease
1 . cryoprecipitate : factor VIII 100 u serious viral transmission 2 lyophilized factor VIII conc . 1 ขวด
250 u 3. L LLLL LLLLLL LLL LL LLLLLL LLLL :250,
500,1,000 U 4. monoclonal purified factor VIII
Hemophilia A
1. prothrombin complex concentrates : factors II, VII, X , IX,
ass with thrombogenic risk 2. cyro-remove plasma
3. monoclonal or recombinant product
Hemophilia B
Dosing• calculated from
1.BW (kg), 2.volume of distribution
3. desired factor level 05Vd factor VIII ~ . ; 1 u/Kg
2 % activity Vd factor IX : 1 u/Kg 1 %
activity desired factor level = severity and locati
on of bleeding episode.
Concentration = dose administration/Vd
= 1 U/0.5
= 2 U/cc = 2% activity
Initail maintenance
dental surgery 50 %
Single + antifibrinolytic
- 710 days
major procedurLL •Extensive dental Sx •LP,epidural anesth •CNS •major orthropedic (TKR)
60 -100
- 3050% until wound healed, ~ 2-3
days- 710 days 3 week ( + PT)
• Factor levels checked• T1/2 - factor VIII 8 12 hours repeated 1 2
LLLL - 16 17factor IX : hours every day
continuous infusion • - 2 4factor VIII : U/kg / hr• LLLLL LLLLLLL
Must check factor VIII inhibitor• Low < 10 bethesda : High dose factor VIII + 10 U/kg/1 BU• Plasmaphoresis• High titer : Porcrine , Recombinant factor
VIIa
OTHER THERAPIES
1. dDAVP : mild moderate bleeding in mild hemo
philia A,2 . Antifibrinolytic – Tranexamic acid and EACA3. microfibrillar collagen, fibrin glue
uizผู้��ป่วยชาย 26 ป่� BW 60kg hemophilia A มาด�วย ขาขวาบวม มา 6ป่�
• 05Body weight x . units/kg x desired fa L LLLLL LLLLLL LLLL LLLLLLLL(%)=
BW x 0.5 x % = unit
60 05 100x . x = 3000 uni t s f act or VI I I
then 60 05 50x . x = 1500 uni t s f act or VI I I
• Cyroprecipitae 100 u/bag = 30 U then 15 u every 12 hr
1.. risk of thromboembolism 2. Risk of bleeding with anticoagulant
anticoagulation
anticoagulation
1. risk of thromboembolism= indication for anticoagulation,
1. actual treatment.1.1 Venous recurrent : first month 1 % /
days 1.2 Artery recurrent : first month 0.5 %/
day avoid e lective surgery DVT: within 2 weeks or if
risk of bleeding is high, vena caval filter
2. prophylaxis ArterialLLLLL LLLL LLLLLL
low risk1 . nonvalvular atrial fibrillation2 . 4prosthetic heart valve % L-year• mitral valve twice risk aortic valve• Aortic: safety of temporary cessatio
L- high risk AF
2. Risk of bleeding depend on age, other disease, drugs,
type of surgery , anticoagulant regim en and intensity,
prolonged, complex, and major sur gery
LLLL bleeding 3% of major postoperative bleedi
ng fatal
1. after discontinued require - 2 3 days f or effect to resolve
2. - Require 4 5 days to resumed a therap eutic level
3. Rebound hypercoagulability after discontinued
• Surgery increases risk of venous not - 100arterial thromboembolism , fold r
isk• changes in hemostatic
markers( acute phase response and w ound healing process)
Must know
1. Heparin : Discontinue 6 hr before• protamine:2. Enoxaparin • 12Antifactor Xa activity: ~ hr
24 hr• protamine 3. warfarin • Vit K • PT - 1214normal hours
• High risk thomboembolism heparin 1. High risk arterial thomboembolism 2. After venous thomboembolism in 1
month ( artery if low risk bleeding)
• - 12Restarting warfarin on postoperativL LLL
LLLLL LLL LL LLLLL L L L4 8 oursbef ore hepari n i s di scont i nued.
Post operative anticoagulant
uizผู้��ป่วย Rheumatic heart disease S/P DVR ฟั'นผู้( ท นตแพทย"แนะน$าให�ถอนฟั'น
• check INR• Reduce dose uutil INR < 2• Tranexamine• Splint
.cancer
1.effects of malignancy 2.side effects of therapy
• Neutropenia and lymphopenia infection. postponed except emergent Even neutropenia resolved remain relatively immunocompromised • Thrombocytopenia • Hypercoagulability : risk for perioperative DVT
airway •Anterior , middle mediastinal masses compress •Flow volume loops Cardio•Pericardial disease
–
•Hepatotoxicity •Nephrotoxicity• cardio : anthracyclines, 550
mg/m 2 doxorubicin Preexisting heart disease, radiation, other chemotherapeutic agents (taxanes) EKG , echocardiogram
radiation therapy 1.Hypothyroidism – Radiation > 10
Gy to neck2.Coronary artery disease , valvular disease
Chemotherapy
uiz6. ชายไทย 38 ป่� ป่วดท�องน�อยด�านขวา มา 2 ว น dx acute appendicitis CBC preop
Hct 22 WBC 5,600 Blast 96 % neutrophil 2% Plt 65,000
uiz• R/O TYphitis• Check PT , APTT• LPB , PLt
Drug dosage1. IVIG AIHA 1000very high doses ( mg/kg/ L 5
LLLLL ITP : <50,000/ ต L-L LLLL 12 LL LL LL LLLLLLLL LLLLLLLL LLLLL LL LL 40/ 1020/2 03 0.
30mg/kg per minLLLLLLLLL LL LLLLLLLL LLL LLLLL LLLLLLLL
1. Competitive inhibition of autoantibody adsorption to patient's platelets.
2. Prevention of RE uptake of- -autoantibody coated platelets through Fc recep
tor blockade.
-3. Interaction of autoantibodies with anti idiot ype antibodies in IVIG.
2 . -25 6tranexamic acids mg/kg / dose every 8 ,
• LLLLL LLLLLLLLLLL ,: - L-L LLLL1. ..: 10 / ,25/ / 34 / 28
- 2 25 34. Oral: mg/kg times/day beginning 1 day prior Sx
3. - 10 34I.V.: mg/kg times/day in unable oral RENAL IMPAIRMENT
• - LL LLLL LL L5 0 8 0 /: 5 0 % L L L LLL1 0 / . . 1 5 /
L LLLLLLL• - 1050 25Clcr mL/minute: % of normal d
LLL LL ODL• 1010 48Clcr< mL/minute: %ofnormaldose or ever y hour sLLLLL : 100 10 100Injection, solution: mg/mL( mL) maximumrateof mg/mi nut e
: oral : 250-500
- 3 75100 6. EACA is mg/kg /dose every hours 4 . NOVOSEVEN 50-100 µg/kg every 2-3 hrs until stop than plus 1-2 dose
5. Pulse methylprednisolone LLLLL L LL(1 , 3ses)
6. dDAVP
1 IV 03 50. microg/kg in mL saline over - 15 30min
LLL L LLLL LLLLLLLLLLLLLL 2 3 3intranasally microg/kg
LLL LLLL LLLLLLLLL 1 . .. 2.vasodilatation facial flushing, headach
L 3. hypotension and hypertension
7. Estrogen1. 0.6 /mg kg IV ,OD 5 days : onset 6hr 14 days 2. - LL LLLL LLLLLLLL 25 25 : onset 2 days 5 dasys3. - 50 100or microg of transdermal twice weLLLL
8. :protamine1.Heparin 1 100mg per units2.Enoxaparin : 1 mg per 1 mg.• Monitor aPTT 2-4 hrs after first infusion• readministration 50% of original dose• Note: anti-Xa activity is never completely
neutralized (60% to 75%). 9. Vit K - -LL LLL: 5 25 6 12
L-L LLL.., .., : 10 12
&
• ผู้��ป่วย Rheumatic heart disease S/P DVR ฟั'นผู้( ท นตแพทย"แนะน$าให�ถอนฟั'น
• ชายไทย 34 ป่� CKD จาก polycystic kidney disease On regular hemodialysis 3 /สั ป่ดาห" น ดมาท$า kidney transplantation
• DM , HT , CKD Cr 2.5 มาด�วย acute febrile illness Dx melioid sepsis , acute ontop chronic kidney disease , severe metabolic acidosis , plan acute peritoneal dialysis
• ผู้��ป่วยชาย 26 ป่� hemophilia มาด�วย ขาขวาบวม มา 6 ป่�• ผู้��ป่วยหญิ�งไทยคู่�� 35 ป่� เป่�น SLE (DLE, ANA,anti DsDNA, LN) on prednisolone (5) 2*2 Dx acute gangrenous arterial occlusion left leg CBC : Hct 21 , WBC 1,600 N 45 % L 50% Plt 600,000 )• ผู้��หญิ�ง 18 ป่� CVT consult preoperative mediastinal mass พบ anemiaCBC : Hct 18 WBC 5,600Plt 560,000
• ชายไทย 38 ป่� ป่วดท�องน�อยด�านขวา มา 2ว น dx acute appendicitis CBC preop Hct 22 WBC 5,600 Blast 96 % neutrophil 2% Plt 65,000